Basic Adult Health Care NCLEX Questions
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Question 1 of 5.
A 62-year-old male is dying from metastatic lung cancer, and all treatments have been discontinued. The client's breathing pattern is labored, with gurgling. The client's wife asks the nurse, 'Can't you do something to help with his breathing?' Which of the following is the nurse's best response in this situation?
A. Direct the unlicensed personnel to assess the client's vital signs and provide oral care.
B. Suction the client so that the client's wife knows all interventions were performed.
C. Reposition the client, elevate the head of the bed, and provide a cool compress.
D. Explain to the wife that it is standard practice not to suction clients when treatments have been discontinued.
Explanation: Repositioning, elevating the head of the bed, and using a cool compress can alleviate labored breathing and gurgling (death rattle) in a dying client, providing comfort without invasive measures.
Question 2 of 5.
If the client who was admitted for myocardial infarction (MI) develops cardiogenic shock, which characteristic sign should the nurse expect to observe?
A. Oliguria.
B. Bradycardia.
C. Elevated blood pressure.
D. Fever.
Explanation: Cardiogenic shock causes decreased cardiac output, leading to reduced renal perfusion and oliguria (low urine output). Bradycardia, elevated BP, and fever are not typical signs.
Question 3 of 5.
Contraindications to the administration of tissue plasminogen activator (t-PA) include which of the following?
A. Age greater than 60 years.
B. History of cerebral hemorrhage.
C. History of heart failure.
D. Cigarette smoking.
Explanation: A history of cerebral hemorrhage is an absolute contraindication to t-PA due to the risk of bleeding. Age, heart failure, and smoking are not contraindications.
Question 4 of 5.
A client with angina has been taking nifedipine. The nurse should teach the client to:
A. Monitor blood pressure monthly.
B. Perform daily weights.
C. Inspect gums daily.
D. Limit intake of green leafy vegetables.
Explanation: Nifedipine, a calcium channel blocker, can cause gingival hyperplasia. Daily gum inspection helps detect this side effect early.
Question 5 of 5.
A client is scheduled for a cardiac catheterization. The nurse should do which of the following preprocedure tasks? Select all that apply.
A. Administer all ordered oral medications.
B. Check for iodine sensitivity.
C. Verify that written consent has been obtained.
D. Withhold food and oral fluids before the procedure.
E. Insert a urinary drainage catheter.
Explanation: Checking iodine sensitivity (B), verifying consent (C), and withholding food/fluids (D) are standard pre-catheterization tasks to ensure safety and preparedness.
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